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Nephro > Nephro > Flashcards

Nephro Flashcards

1
Q

Factors that control renal blood flow

A
  • Systemic arterial pressure
  • Circulating volume
  • Renal and vascular resistance
  • autoregulation
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2
Q

Describe the distribution of renal blood flow

A
  • 90% RBF goes to cortex (flow 500ml/min to 100 g tissue)
  • 10% RBF goes to medulla (outer zone =100ml/min per 100g tissue vs inner zone is 25ml/min)
  • **CHANGES IN RBF WILL LARGELY REFLECT CHANGES IN CORTEX
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3
Q

Uses of kidney US

A
  • To quantify kidney size
  • To evaluate for hydronephrosis
  • To evaluate the perirenal space for abscess or hematoma
  • To screen for ADPKD
  • To localize the kidney for invasive procedures
  • To evaluate for kidney vein thrombosis (doppler US)
  • To assess kidney blood flow (doppler US)
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4
Q

Uses of kidney IVP

A
  • To assess renal size and contour
  • To investigate recurrent urinary tract infection
  • To detect and locate calculi
  • To evaluate suspected urinary tract obstruction
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5
Q

Uses of radionuclide studies in kidney

A
  • To quantify total kidney function and the contribution of each kidney
  • To evaluate kidney parenchymal integrity
  • To evaluate kidney infection or scar
  • To evaluate renovascular hypertension
  • Little benefit when the single kidney GFR is below 15 ml/min
  • Most use 99 technetium
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6
Q

uses of CT in kidney

A
  • To further evaluate a renal mass
  • To display calcification pattern in a mass
  • To delineate the extent of renal trauma
  • To guide percutaneous needle aspiration or biopsy
  • To diagnose adrenal causes for hypertension
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7
Q

uses of MRI in kidney imaging

A
  • Diagnosing renovascular lesions
  • To assess renal vein thrombosis
  • Evaluation of potential living kidney donors and transplanted kidneys
  • To evaluate suspected pheochromocytoma
  • Delineating complex mass where CT is not definitive
  • Staging kidney neoplasms, particularly in evaluating for renal vein or inferior venal caval extension of tumor
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8
Q

Angiography in kidney imaging

A

Suspected artery lesions: atherosclerotic or fibrodysplatic stenoic lesions of the renal arteries, aneursysms, arteriovenous fistulae.
• Large vessel vasculitis
• Unexplained hematuria
• Kidney transplantation
• Diagnoses for renal vein thrombosis
• Complex or highly unusual renal masses or trauma etc
*can be diagnostic or therapeutic

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9
Q

Uses of kidney biopsy

A

• The cause cannot be determined or adequately predicted by less invasive diagnostic procedure
• The signs and symptoms suggest parenchymal disease that can be diagnosed by pathologic evaluation
• The differential diagnosis includes diseases that have different treatments, different prognoses, or both.
(Acute renal failure; Nephrotic or nephritic syndrome; Hematuria; Systemic Disease)
• Transplant Allograft

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10
Q

FENa

A
  • Fraction of filtered Na that is excreted
  • Expect to be low if: kidney is Na avid, tubules are intact
  • Calculate: FENa=U[Na]/P[Na] x P[Cr]/U[Cr]
  • Most useful in oilguric renal failure
  • FENa<1% can be seeni n causes of ARF (other than pre-renal azotemia)
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11
Q

What sorts of things can you detect by urinalysis?

A
  • Blood (strip detects peroxidase): blood, myoglobin, free hemoglobin
  • Neutrophils (Leukocyte alkaline esterase)
  • Nitrate (azo dye)→presence suggests bacteria
  • Protein
  • Specific gravity approximates osmolality→high specific gravity then urine concentrating ability is intact
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12
Q

determining GFR with serum creatinine

A

• Estimate w/ serum creatinine clearance (calculated with formulas, depends on age, sex, race, weight etc)
o Hyperbolic relationship b/t GFR and Scr concentration (large changes in GFR are reflected as small changes in Scr)
o Pt must be in steady state! (conditions can change Scr w/o affecting GFR eg: hepatic cirrhosis, limb amputation, spinal cord injury, morbid obesity)
• Large muscle mass can inc. Scr
• Cimetidine, trimethoprim, probenecid all block proximal secretion and inc. Scr
• Ketones, methanol, cephalosporins, isopropanol all interfere with jaffe reaction and inc. Scr

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13
Q

clinical manifestations of ARF

A 
o	Elevated serum BUN and creatinine
o	Urine output:
•	Anuria (400 cc/day)
o	Metabolic acidosis (dec. bicarb
o	Hyperkalemia
o	Hyperphosphatemia/Hypocalcemia
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14
Q

complications of ARF

A

oMetabolic: hyperkalemia, hypocalcemia, hyperphosphatemia
oCardiovascular: pulmonary edema, arrhythmias, hypertension, pericarditis
oNeurologic: asterixis, somnolence, coma, seizures
oHematologic: anemia, coagulopathies, bleeding diathesis
oGastrointestinal: nausea, vomiting, hemorrhage, mucous membrane ulceration
oInfections: urinary tract infection, wound infection, pneumonia

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15
Q

supportive care management of ARF

A

o Intravascular volume overload (Low Salt diet, Water restriction (15
o Hyperphosphatemia, Hypermagnesemia, Hypocalcemia (Phosphate binding agents (CaAcetate, Sevelamer), avoid milk; Discontinue Mg containing antacids (Mylanta, Maalox); Ca-gluconate, Ca-carbonate)

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16
Q

Key points prerenal azotemia

A
  • decrease in effective circulating blood volume
  • kidney is intact
  • major causes: hypovolemia, cardiac–CHF, MI, peripheral vasodilation, increased renal vascular resistance
  • urine lytes: FENa20, Osm>500,
  • inc. serum BUN/Creatinine
  • Tx: replace fluid, tx CHF
  • complete recovery if perfusion restored
17
Q

Key points post-renal obstruction

A
  • must have bilateral obstruction for symptoms
  • urethral obstruction, bladder neck obstruction (tumors, BPH), intrauretal, extrauretal
  • obstruction on imaging (urine lytes not helpful)
  • Sx of frequency/urgency (can have anuria)
  • complete recovery if obstruction removed quickly
18
Q

Key points Acute tubular necrosis

A

-sudden death of tubular (not glomerular) cells!
-can be ischemic or caused by nephrotoxic agents
-urine sedimentation: granular casts
urine lytes: FENa>1%, Na>20
-no tx available
-pts will mild injury will recover completely, the worse the injury the less likely they are to recover

19
Q

key points Acute interstitial nephritis

A
  • allergic reaction usually to a drug (requires 1-2 wks of exposure)
  • Hx: drug hypersensitivity (skin rash, urticaria, fever, athralgia)
  • peripheral eosinophil >10%
  • Urine WBCs with negative urine culture
  • WBC casts w/o evidence of pyelonephritis
  • Gold standard: Biopsy
20
Q

key points acute glomerulonephritis

A
  • inflammation of glomeruli (typically auto-immune)
  • assoc w/ other autoimmune diseases
  • urine sedimentation: dysmorphic RBCs, RBC casts, WBC casts, proteinuria
21
Q

key points renal athero-emboli

A
  • small atheromatous crystals flick off arterial wall and embolize to the kidney
  • typically due to manipulation of arteries
  • no treatment
  • renal function rarely recovered
22
Q

grading renal dysfunction in terms of creatinine clearance

A

o Cl creat 60-99 ml/min = mild impairment
o Cl creat 30-59 ml/min=moderate impairment
o Cl creat 15-29 ml/mim = severe impairment
o *renal replacement therapy usually at clearance of 5-10

23
Q

stages of chronic renal failure

A 
o	Stage 1: normal GFR, but signs of kidney disease-e.g. proteinuria
o	Stage 2: GFR 60-99
o	Stage 3: GFR 30-59
o	Stage 4: GFR 15-29
o	Stage 5: GFR <15
o	Stage 6: On renal replacement therapy
24
Q

symptoms of mild chronic renal failure

A

: minimal fatigue, salt and H2O retention causing edema and hypertension

25
Q

symptoms of moderate chronic renal failure

A

more fatigue and edema. MILDLY IMPAIRED cognition. Appetite preserved.

26
Q

symptoms, signs, and lab abnormalities of severe chronic renal dysfunction

A

-marked fatigue, loss of appetite→nausea and vomiting
• Signs: asterixis, seizures, pericardial friction rub
Lab abnormalities:
• Prolonged bleeding time (platelet dysfunction)
• Profound anemia
• Low calcium and high phosphate (sometimes subperiostial bone resorption on xray)
• High alk phos (secondary hyperparathyroidism)
• High potassium

27
Q

complications of uremia

A
  • Anemia, pulmonary edema, vascular calfication, severe acidosis, bone disease (can be minimized with medical management)
  • Central and peripheral nervous system dysfunction, pericarditis, malnutrition (avoid with institution of renal replacement therapy)
28
Q

preservation of GFF in chronic renal failure

A 
o	Renal disease is progressive=progressive glomerular damage
o	Hyperfiltration injury
o	Efferent vs afferent vasoconstriction
o	Tight BP control (<130/80)
o	Diuretics
o	Disruption R/A system
o	ACEI and ARB (renin inhibitors)
29
Q

anemia in chronic renal failure

A

o Begins at GFR<60ml/min (as GFR gets worse, anemia gets worse)
o Major cause is EPO deficiency
o Tx w/ EPO injection, iron supplments (target Hgb is ~10 (not to normal))
• w/ correction of anemia pts have inc. well being, reversal of LVH, improved cognition and life expectancy

30
Q

platelet dysfunction in chronic renal failure

A

o Prolonged bleeding time
o Is an issue w/ bleeding ulcers, surgery etc
Tx:
• Desmopressin (inc. vWF and factor 8): tachyphylaxis after 2nd dose
• Cryoprecipitate
• PRCB to hct>30%

31
Q

metabolic acidosis in chronic renal failure

A

o Decreased serum bicarb→high anion gap
o Bicarb <16 is symptomatic
o Tx w/ oral bicarb or citrate

32
Q

osteitis fibrosa

A
  • complication of severe chronic renal failure
  • High PTH due to hypocalcemia (low calcitriol), hyperphosphatemia (decreased GFR)→rapid bone turnover and abnormal bone (woven vs trabecular)
  • Tx: suppress PTH (but still higher than nl), correct calcium, keep phosphate low
33
Q

low bone turnover disease

A

-complication of chronic renal failure
–>vascular calcification, valvular calcification
• High calcium X phosphate
• Low PTH
• Can be from overzealous management of PTH w/ phosphate binders containing calcium

34
Q

osteomalacia

A

-complication of chronic renal failure
• Iatrogenic
• Heavy metal (aluminum) deposits at calcification front in bone
• Don’t’ use aluminum hydroxide as phosphate binder

35
Q

dietary considerations in chronic renal failure

A

o Protein restriction: malnutrition vs. minimal renal preservation effect
o Potassium: 2 gram restriction. Usually clearance less than 25 ml/min
o Low phosphate with stage 3-4 CKD
o Sodium restriction: from day one
o Fluid – very variable

36
Q

renal replacement therapy in chronic renal failure

A

hemodialysis vs transplant (sig. complications, but overall better survival!!)

37
Q

Physical exam assessment of volume status

A
  1. orthostatic (BP, pulse, symptoms of dizziness)
  2. pitting edema
  3. Weight
  4. Urine output/concentration
  5. 3rd spacing of fluids
  6. CHF

Nephro (5 decks)

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